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Thoughts on Kevin Ware’s Injury

The University of Louisville Cardinal guard Kevin Ware sustained a horrifying tibia fracture in the Midwest Regional final today against Duke. CBS insisted on showing multiple slow motion replays that demonstrated Ware’s tibia breaking and then puncturing through the skin. While the injury looked extremely gruesome, there is still a favorable prognosis for Ware. It is certainly a season-ending type of injury, but not career-threatening. Notable players with similar injuries are Joe Theismann, Michael Bush, Edgar Sosa, and Sid Vicious (for you wresting fans out there).

Example of an intramedullary nail.

What makes Ware’s injury different is the open, or compound, nature of the fracture. When the bone punctures the skin, many things change about the treatment and the healing of the fracture. The first concern is infection, since the fracture is directly exposed to the outside environment. The single most important factor in lowering the infection risk is the time it takes to get the patient to the operating room and cleaning the wound. The medical staff in Indianapolis did an excellent job with this, as early reports stated that Ware was in surgery within 2 hours.

The next concern about open fractures is the blood supply to the bone. In an open fracture such as this the periosteum, or tissue lining the bone, is stripped off. The periosteum is where the bone gets its blood supply, which is essential for fracture healing. Open fractures typically take several weeks longer to heal and have a higher rate of non-union, which means a non-healed fracture that requires a second surgery.

Example of a mid-shaft tibia fracture.

I obviously have not seen any X-rays of Ware’s injury, but based on the television replay it appeared to be a shaft fracture of the tibia and fibula. The tibia is the main weight bearing bone of the leg, so treatment is focused on this and not the fibula. The standard treatment of a tibia shaft fracture is an intramedullary nail, which is a large rod made of stainless steel or titanium that is placed inside the bone and held in place with screws at each end to stabilize it. The tibia can be thought of as a hollow tube, and the rod goes inside the tube to provide alignment and support. Many times, after stabilizing a tibia fracture with a nail, the patient can start putting some weight on the leg right away.

Open tibia fractures are very often high-energy injuries seen in automobile and motorcycle accidents. It is unusual to see this type of injury when a player is simply landing from a jump. The way that Ware’s tibia snapped as soon as he landed makes me wonder if he already had a stress fracture in the tibia and was just playing through the pain. Sometimes players don’t even report aches and pains that they may have for fear of losing playing time. Stress fractures, if untreated, can eventually lead to injuries such as this. This is pure speculation, but in my mind it helps explain why his leg broke the way that it did.

It is much too early to make predictions on healing time until more details are known, but it is not unreasonable to believe that Kevin Ware could be playing basketball by the time next season gets underway.

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Dr. Carter, what — if any — long-term side effects have been experienced by people with intramedullary nails? Do they have trouble with temperature or pressure changes?

Thanks in advance for your response!

Dr. Samuel CarterApril 13, 2013

Temperature or pressure changes do not generally cause any problems with IM nails. Some patients experience some patellar tendon irritation from the entry point of the nail at the knee. In very thin patients, the locking screw heads at the knee and ankle may be irritating. The nails are generally removed after a year or so once the fracture has solidly healed. I hope this helps.